L’incidence d’évènements liés à la chaleur (ÉLC) augmentera en raison des changements climatiques, du vieillissement et de l’urbanisation. Cette étude vise à dresser le portrait de la vulnérabilité des aînés aux ÉLC, à déterminer leur incidence et leurs déterminants ainsi qu’à construire un indice de vulnérabilité à la chaleur des personnes âgées (IVCPA). Une étude de cohorte prospective a été réalisée chez des aînés vivant en communauté dans les régions de l’Estrie, de Montréal et de Laval enrôlés dans l’ « Étude longitudinale québécoise sur la nutrition comme déterminant d’un vieillissement réussi ». La prévalence des facteurs de risque ou de protection de nature médicale, sociale et environnementale, préalablement identifiés dans les lignes directrices de Santé Canada, a été examinée auprès de 1679 personnes en 2005-2006. Les données sur les événements mesurés sur une période de cinq années (2006 à 2010) étaient disponibles pour 1233 participants et provenaient de la Régie de l’Assurance Maladie du Québec et de Med-Echo. Ils ont été considérés comme liés à la chaleur s’ils survenaient un jour de température élevée (JTÉ; ≥30oC) du 15 mai au 15 septembre (2006 à 2010). Des analyses de régression logistique multivariées ont permis d’examiner les associations entre les facteurs, l’IVCPA et deux événements : 1) visite à l’urgence liée à la chaleur (VULC) et 2) tout ÉLC. Les résultats montrent que la vulnérabilité des aînés aux ÉLC est élevée et diffère selon les régions. Les visites à l’urgence, les hospitalisations et les décès sont, respectivement, 2,6, 1,7 et 1,3 fois plus fréquents les JTÉ que les jours de température normale. Une autonomie et un revenu faibles sont associés à un risque accru de VULC (rapport de cotes ajusté (RCA)=2,7; intervalle de confiance (IC) à 95%: 1,1-5,4 et RCA=3,2; IC à 95%: 1,1-8,5 respectivement) et d’ÉLC (RCA=2,5; IC à 95%: 1,1-5,6 et RCA=2,8; IC à 95%: 1,1-7,6 respectivement). À l’inverse, une participation sociale élevée est associée à une diminution marquée du risque de VULC (RCA=0,05; IC à 95%: 0,01-0,2) et d’ÉLC (RCA=0,04; IC à 95%: 0,01-0,2). Les aînés présentant simultanément six facteurs augmentant leur vulnérabilité étaient sept fois plus à risque de VULC (rapport de cotes (RC)=7,4; IC à 95%: 1,5-36,2) ou d’ÉLC (RC=7,8; IC à 95%: 1,6-37,2) comparativement à ceux avec aucun ou un seul facteur. L’identification des aînés les plus vulnérables permettra de développer des stratégies d’intervention clinique et communautaire davantage ciblées.

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Yes / The most common route to a hospital bed in an emergency is via an emergency department (ED). Many recent initiatives and interventions have the objective of reducing the number of unnecessary emergency admissions. We aimed to assess whether ED admission thresholds had changed over time taking account of the casemix of patients arriving at ED. Methods: We conducted a retrospective cross-sectional analysis of more than 20 million attendances at 47 consultant-led emergency departments in England between April 2010 and March 2015. We used mixed- effects logistic regression to estimate the odds of a patient being admitted to hospital and the impact of a range of potential explanatory variables. Models were developed and validated for four attendance subgroups : ambulance-conveyed children; walk-in children; ambulance-conveyed adults; and walk-in adults. Results: 23.8% of attendances were for children aged under 18 years, 49.7% were female and 30.0% were conveyed by ambulance. The number of ED attendances increased by 1.8% per annum between April 2010 – March 2011 (year 1) and April 2014 –March 2015 (year 5). The proportion of these attendances that were admitted to hospital changed little between year 1 (27.0%) and year 5 (27.5%). However, after adjusting for patient and attendance characteristics the odds of admission over the five year period had reduced by: 15.2% (95% CI 13.4% - 17.0%) for ambulance-conveyed children; 22.6% (95% CI 21.7%-23.5%) for walk-in children; 20.9% (95% CI 4%-21.5%) for ambulance conveyed adults; and 22.9% (95% CI 22.4%-23.5%) for walk-in adults. Conclusions: The casemix-adjusted odds of admission via ED to NHS hospitals in England have decreased since April 2010. EDs are admitting a similar proportion of patients to hospital despite increases in the complexity and acuity of presenting patients. Without these threshold changes, the number of emergency admissions would have been 11.9% higher than was the case in year 5.

Tradicionalmente o planejamento de provisão de internações baseia-se em comparações nacionais e internacionais em vez da eficácia de políticas de curta e de longa permanência. Estudos sobre as causas e consequências das internações psiquiátricas de longa permanência têm uma relação direta ao tamanho e provisão de instalações que têm um maior impacto sobre como os recursos são utilizados.Objetivo:Identificar fatores de exposição associados ao tempo de permanência prolongado em internações psiquiátricas.Metodologia: estudo caso controle realizado no hospital psiquiátrico de Uberaba. Os casos foram todos os pacientes com internações com permanência superior a 60 dias contínuos no período de janeiro de 2014 a dezembro de 2014. Os controles escolhidos aleatoriamente, pareados por sexo e idade. Características epidemiológicas e sociodemográficas relacionadas às internações psiquiátricas de longa permanência foram descritas e realizadas comparações entre as diversas variáveis. Análise multivariada por regressão logística foi realizada para determinar variáveis preditoras de internação psiquiátrica de longa permanência.Resultados:selecionou-se 216 pacientes, 72 casos (5,5% do total de internações) e 144 controles; 63,9% do sexo masculino; a média de idade foi de 44,4 anos (DP±11,9); a procedência distribuiu-se entre 53% do próprio município de Uberaba e o restante entre 43 outros; o tempo de permanência foi de 84,8 dias (DP±31,4; IC95%: 77,4-92,2) entre os casos e de 33,2 dias (DP±10,8; IC95%: 31,5-35,1) entre os controles (p<0,05). A média do tempo de permanência para pacientes com motivo de internação com risco para si ou terceiros foi de 38,7 dias (DP±24,1) e para os com motivo sem tal risco foi de 59,3 dias (DP±33,7) (p<0,05). Houve associação com o desfecho, em análises univariadas e multivariadas por regressão logística do motivo da internação por incapacidade de autocuidado e/ou falência do suporte familiar e/ou social (OR 3,61; [IC95%: 1,91-6,82]). Conclusão:os resultados do estudo concordam com a literatura internacional. Em nosso país não existem estudos de custo-eficácia deste tema. Recomenda-se mais estudos analíticos que investiguem a qualidade de vida de pessoas que tenham internações psiquiátricas de longa permanência, visando tanto o processo de planejamento da alta e o pós alta, utilizando critérios amplos sem focalizar categorias definidas de doenças. / Background:Traditionally, hospitalisation planning is based on national and international comparisons rather than the effectiveness of short-term and longterm policies. Studies on the causes and consequences of long-stay psychiatric hospitalisations have a direct relationship to the size and provision of facilities that have a greater impact on how the resources are used. Objective: To identify exposure factors associated with long stay in psychiatric hospitalizations. Methods: a case control study performed at the psychiatric hospital of Uberaba, Minas Gerais. Cases were all patients with hospitalisations with stay over 60 continuous days from January 2014 to December 2014. The randomly chosen controls, matched by sex and age. Epidemiological and sociodemographic characteristics related to long-stay psychiatric hospitalisations were described and comparisons were made between the several variables. Multivariate analysis by logistic regression was performed to determine predictors of long-stay psychiatric hospitalisation. Results: 216 patients were selected, 72 cases (5.5% of all hospitalisations) and 144 controls; 63.9% male; the mean age was 44.4 years (± 11.9); the origin was distributed between 53% of Uberaba itself and the rest among 43 other cities; the length of stay was 84.8 days (± 31.4; CI95%: 77,4-92,2) between the cases and 33.2 days (± 10.8; CI95%: 31,5-35,1) between the controls (p <0.05). The mean length of stay for patients with risk for themselves or others was 38.7 days (± 24.1) and for those without that risk was 59.3 days (± 33.7) (p <0, 05). There was an association with the outcome in univariate and multivariate analyzes by logistic regression of the reason for hospitalisation due to incapacity for selfcare and/or family and/or social support failure (OR 3.61; 95% CI: 1.91-6.82 ]). Conclusions: the results of the study agree with the international literature. In our country there are no cost-effectiveness studies of this topic. More analytical studies are recommended that investigate the quality of life of people with longstay psychiatric hospitalisations, aiming at both discharge process and postdischarge planning, using broad criteria without focusing on defined categories of diseases.

Despite generous universal social health insurance with little formal restrictions of outpatient utilisation, Austria exhibits high rates of avoidable hospitalisations, which indicate the inefficient provision of primary healthcare and might be a consequence of the strict regulatory split between the Austrian inpatient and outpatient sector. This paper exploits the considerable regional variations in acute and chronic avoidable hospitalisations in Austria to investigate whether those inefficiencies in primary care are rather related to regional healthcare supply or to population characteristics. To explicitly account for inter-regional dependencies, spatial panel data methods are applied to a comprehensive administrative dataset of all hospitalisations from 2008 to 2013 in the 117 Austrian districts. The initial selection of relevant covariates is based on Bayesian model averaging. The results of the analysis show that supply-side variables, such as the number of general practitioners, are significantly associated with decreased chronic and acute avoidable hospitalisations, whereas characteristics of the regional population, such as the share of population with university education or long-term unemployed, are less relevant. Furthermore, the spatial error term indicates that there are significant spatial dependencies between unobserved characteristics, such as practice style or patients' utilization behaviour. Not accounting for those would result in omitted variable bias.

Thèse numérisée par la Division de la gestion de documents et des archives de l'Université de Montréal.

Améliorer la qualité de la prise en charge des personnes âgées vivant en EHPAD est un impératif. L'influence des caractéristiques organisationnelles des EHPAD sur la qualité de la prise en charge des résidents est mal connue. Nos travaux de recherche ont porté sur trois objectifs : 1) Rechercher les facteurs organisationnels en EHPAD qui ont un impact sur les prescriptions potentiellement inappropriées de neuroleptiques, ces médicaments faisant l'objet d'une attention particulière chez les personnes âgées en EHPAD ; 2) Déterminer la valeur ajoutée de l'intervention d'un gériatre au sein d'EHPAD pendant 18 mois par rapport à la restitution simple d'un audit qualité, sur les prescriptions potentiellement inappropriées de neuroleptiques ; 3) Proposer des actions concrètes d'amélioration de la prise en charge globale des résidents d'EHPAD concernant notamment les transferts inappropriées des résidents d'EHPAD vers les urgences, et la prévention du déclin fonctionnel des résidents. Pour répondre aux deux premiers objectifs, nous avons utilisé les données de l'étude IQUARE (Impact d'une démarche QUAlité sur l'évolution des pratiques et le déclin fonctionnel des Résidents en EHPAD) un essai multicentrique comparatif ayant pour objectif d'évaluer l'impact d'une intervention globale d'éducation gériatrique pour le personnel d'EHPAD sur des indicateurs de qualité. Pour le troisième objectif, nous proposons d'une part la structuration d'un hôpital de jour ayant pour vocation de ne recevoir que des résidents d'EHPAD avec la possibilité de les prendre en charge dans des délais courts afin de limiter les transferts inappropriés des résidents d'EHPAD vers les urgences. D'autre part, nous avons participé à une task force d'experts composée de médecins gériatres cliniciens et chercheurs dont l'objectif était de proposer des actions de prévention du déclin fonctionnel des résidents d'EHPAD. Sur les 6275 résidents inclus dans IQUARE, 1532 (24.4%) avaient au moins une prescription de neuroleptique parmi lesquels 1019 (66.5%) étaient potentiellement inappropriées. Nous avons montré que les résidents d'EHPAD dans lesquels intervenait un nombre important de médecins généralistes différents (plus de 30 pour 100 lits), étaient plus à risque de recevoir une prescription inappropriée de neuroleptiques que ceux vivant dans des EHPAD avec moins de 10 médecins généralistes pour 100 lits. Dans cette même étude IQUARE, nous n'avons pas mis en évidence d'effet positif de l'intervention d'un gériatre au sein d'EHPAD pendant 18 mois par rapport à la restitution simple d'un audit qualité, sur la réduction des prescriptions inappropriées de neuroleptiques 18 mois plus tard. [...] / Improving the quality of care for nursing home residents is a real concern. A better understanding of the factors determining a good quality of care in nursing homes (NH) is necessary. This thesis deals with three aims: 1) Determining whether facility characteristics - and in particular the number of attending general practitioners (GPs) in NH - are associated with inappropriate neuroleptic prescribing ; 2) Studying the effect of a quality assurance approach in a NH, with or without the intervention of a geriatrician, on potentially inappropriate neuroleptics prescription at 18 months (T18); 3) Offering practical actions improving medical care in NH in order to reduce potentially avoidable transfers to emergency rooms and to prevent disability and functional decline for NH residents. To meet the two first objectives, we used the data from the Impact of a QUAlity exercise study on the change in practices and the functional decline of Residents in EHPAD (IQUARE), a comparative multicenter trial aiming at assessing the impact of a global education intervention for NH staff based on quality indicators. As for the third objective, on the one hand, we implemented a new day hospital characterized by its being exclusively dedicated to NH residents and its ability to provide patient care within a short period of time. On the other hand, we took part in a Task Force discussion of experts in NH care and research, to implement strategies to prevent or to slow disability and functional decline for NH residents.Among the 6275 residents included in IQUARE study, 1532 (24.4%) had at least one prescription for a neuroleptic drug. Compared with nursing homes with <10 GPs/100 beds, nursing homes with more than 30 GPs/100 beds were exposed to a greater risk of potentially inappropriate neuroleptic prescribing. We have not shown the added benefit of geriatrician intervention in a global effort to decrease potentially inappropriate neuroleptic prescribing. This result can be explained by the strong impact of the quality assurance audit restoration at each NH with a 20% decrease of the potentially inappropriate neuroleptic prescribing for the two study groups. Over this thesis, we have opened a responsive day hospital dedicated to NH residents. This day hospital could be a practical response to the problem of inappropriate and avoidable transfers of NH residents to emergency rooms. Improving the quality of care for nursing home residents also means preventing and/or slowing the functional decline of residents. A Task Force of experts emphasized the need for cultural change to incorporate physical activity for nursing home residents and implement multidomain interventions to delay disability. To conclude, this work has identified factors having an influence on potentially inappropriate care and suggests simple areas to improve the quality of care.

Thèse numérisée par la Division de la gestion de documents et des archives de l'Université de Montréal

No description available.

La pancréatite, qui désigne l’inflammation du pancréas, est une condition grave qui survient lorsque les enzymes pancréatiques, servant normalement à la digestion des aliments, digèrent le pancréas. Les causes les plus fréquentes sont la consommation excessive d’alcool et la migration de lithiases vésiculaires dans les voies biliaires. On reconnait également des formes moins fréquentes qui contribuent au fardeau de la maladie et la pancréatite induite par un médicament est l’une d’entre elles. En cours d’hospitalisation et lors du suivi, cette étiologie cause des difficultés aux médecins et aux pharmaciens qui doivent travailler de concert pour d’abord la diagnostiquer, mais également identifier le médicament déclencheur afin d’éviter la récurrence. Néanmoins, cette identification se voit complexifiée, dû à un manque de données probantes fiables et récentes concernant d’une part l’épidémiologie, mais aussi l’étiologie de cette condition. L’objectif principal de ce projet est d’étudier les cas de pancréatites aiguës médicamenteuses hospitalisés au Centre intégré universitaire de santé et services sociaux du Saguenay–Lac-Saint-Jean afin d'obtenir un portrait réel de cette étiologie en plus d’ajouter de nouvelles preuves à la littérature. La méthodologie repose sur la révision des dossiers médicaux des cas hospitalisés pour au moins une pancréatite médicamenteuse dans les six hôpitaux du Saguenay–Lac-Saint-Jean entre 2006 et 2014. Les données recueillies et leurs analyses ont permis de documenter les médicaments ayant causé une pancréatite aiguë médicamenteuse au Saguenay–Lac-Saint-Jean en plus de participer à l’avancement des connaissances actuelles par l’identification de médicaments non associés à la pancréatite aiguë jusqu’à maintenant. / Pancreatitis, which refers to the inflammation of the pancreas, is a serious medical condition in which the pancreatic enzymes, that normally digest food, start to digest the pancreas. The most common causes are excessive alcohol consumption and gallstone migration into the bile ducts. Less common causes also contribute to the burden of the disease and drugs are one of them. Diagnosis of drug-induced pancreatitis and identification of the triggering drug in order to avoid recurrence is a challenge to both physicians and pharmacists. Moreover, identification of the causative drug is complex due to a lack of reliable and recent evidence concerning the epidemiology and the etiology of this condition. The main objective of this project is to study drug-induced acute pancreatitis cases hospitalized at the Centre intégré universitaire de santé et services sociaux of the Saguenay–Lac-Saint-Jean in order to obtain an accurate representation of this etiology in addition to adding new evidences to the literature. The methodology relies on the review of medical records of hospitalized cases for at least one drug-induced acute pancreatitis in the six hospitals of the Saguenay–Lac-Saint-Jean between 2006 and 2014. The data collected and their analyzes document drugs involved in acute pancreatitis in the Saguenay–Lac-Saint-Jean region in addition to participating in the advancement of our current knowledge by describing drugs that had not been associated with acute pancreatitis until now.